Tricare reverses decision to make beneficiary pay for $1,600-per-month medication

Sep. 25, 2013 - 02:33PM
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A Tricare beneficiary who has paid nearly $1,600 a month since June for a prescription that had previously been covered by the military’s health care program received word last week that Tricare again will pay for the medication.

Jean Saunders, 63, of Santa Monica, Calif., has taken Xifaxan for more than a decade to treat symptoms of irritable bowl syndrome. According to her physician, the Xifaxan, also known as rifaximin, is the only thing that reduces Saunders’ “small bowel intestinal overgrowth,” a source of her IBS.

But earlier this year, a Tricare pharmacy advisory panel recommended the pricey medication be covered by Tricare for only its FDA-approved conditions: hepatic encephalopathy or, in some cases, traveler’s diarrhea.

Saunders was notified in June of the decision and reimbursement immediately stopped. She appealed but her request for a waiver was denied.

Saunders’ physician wrote another appeal letter and a story on her dilemma ran in the Military Times newspapers on Sept. 2. On Sept. 19, she received notice by FedEx from Tricare that a physician reviewer had “reversed the denial,” concluding there was “sufficient clinical justification to fill this drug.”

Saunders’ husband, Lloyd, who was spending nearly his entire monthly Navy retirement to pay for the Xifaxan, said he is grateful for the decision — and not just because of the money.

“Of equal value is knowing there are responsible individuals still in a place of authority, such as the doctor who reviewed and reversed the initial denial,” Lloyd Saunders said.

The Saunders have not been alone among Tricare beneficiaries in their frustration with the program’s appeals process.

Earlier this year, the family of a severely disabled Texas teenager, Kaitlyn Samuels, lobbied for legislation to provide horse-based physical therapy for patients after a Tricare hearing officer agreed that the military insurer should cover Kaitlyn’s therapy, but his boss, Tricare Appeals Director Mark Donahue, thought otherwise.

The issues have become so widespread that the Senate earlier this year included a provision in its version of the 2014 defense bill requiring Tricare to submit a report on the appeals process.

The House did not include a request for a report in its version of the defense bill, so negotiators will decide whether it is included in the final compromise bill.